IN NEW ZEALAND

A National Benchmarking Exercise

August 2000

INTRODUCTION

Benchmarking information on a range of issues identified by MidCentral Health
was obtained from nine publicly funded audiology services serving populations
not dissimilar from MidCentral Health. Services from the three main population
centres were not included in the wider aspects of the exercise, although
specific information was sought from some of them regarding best practice.

Thanks are
due to the audiologists and managers of the services involved for their
willingness to participate in this exercise, and for the time they made
available to make the project successful and, hopefully, useful to all
concerned.

CLINICAL PRIORITY AND KEY REVENUE GENERATORS

Waiting times

Average,
maximum and minimum waiting times for the six main categories of audiological
clients are shown in Figure 1. Adult hearing aid clients show the highest
average waiting time (8.7 months), and the largest variation between services (a
range of 1 - 24 months). Details of the waiting times for the various services
demonstrating the wide range are shown in Figure 2. The maximum waiting time for
all other client groups was 4 months.

Clinical priority

The much
greater waiting time for adult hearing aid clients than for other client
categories demonstrates graphically the lower clinical priority that these
clients typically receive. The reason for this disparity is presumably the
availability of private services focussed primarily on this client group. Young
children at risk of hearing loss needing assessment, and those found to have
hearing loss and needing hearing aids were given priority by all services.

Outputs

Total outputs budgeted ranged from 1,292 to
3,100.

Because of
the different formats for presenting outputs, insufficient numbers of services
were available for more detailed comparison.

Populations

Populations
living near the various services varied from just under 55,000 to over 300,000
(based on 1996 census data provided by NZ Health Information Service). The
average was 125,900.

Outputs related to
population

The funded
visits per head of population ranged from a high of 1:34 to a low of 1:107, with
a mean of 1:51.

Revenue generated

In no
hospital did ORL pay for audiometric support services supplied by audiology. In
one case, the ORL department paid for additional time above budget for which an
audiometrist was employed. In another service, work was being carried out on
developing an inter-service agreement.

The price
paid by the Health Funding Authority per visit generally varied from $25 to $100
with an average of $48. In two areas, a higher price had been negotiated for
hearing aid fittings. These prices again varied – in one area the fee was $120,
in another, it was $150 for the initial hearing aid assessment, and $100 for
follow-up visits.

Total
contract prices varied from $48,000 to $312,000.

Revenue
generated did not necessarily correlate with population served. The average
funding per head of population was 77c. The range extended from 23c to $2.08.
There was no obvious population-based explanation for the differences in
funding levels.

Take-up of newer
audiological tests

Otoacoustic
emissions (OAE) were available in four services. A fifth service had approval to
purchase equipment for OAE. In two services OAE was being used to test high-risk
neonates. All those with OAE used it as a crosscheck with adults and children
needing hearing assessment.

Testing for
central auditory processing was available to some extent in all services. Two
provided screening only, and most others commented that although available,
demand was not very high.

ADMINISTRATION PROCESSES

Appointments systems

All
hospitals used computerised systems to make appointments. Five services admitted
to also using manual diaries because they were easier to visualise. In a few
cases these were stand-alone systems, but by far the majority were connected to
the hospital’s main appointments system.

Coordination
of HA appointments

Five
services purchased hearing aids and earmoulds directly (ie without the
involvement of their purchasing departments). In some places, the practice was
to schedule a series of appointments for hearing aid fitting and follow-ups once
the assessment was completed. In others, where deliveries were not so reliable,
no appointments were made until the devices ordered had arrived at the clinic.
Sometimes, appointments were made sequentially. In these cases, the services
tended not to book far in advance, so they were assured of having clinic time
available when required.

Computerised
billing system

Most
services used manual dockets for billing clients for hearing aid purchases. In
four cases, computerised billing followed completion of manual dockets.

Clinical
databases

Clinical
data were generally not stored on computer, apart from hearing aid information
stored through the Noah system. One city hospital not part of the main survey
had networked their laptops so that hearing aid client information was available
at all of their clinical delivery sites. This has proved a useful innovation,
and is well supported by the hospital’s IT and data management services.

Administrative
information

Output
information was available at all services through the appointment systems. This
administrative requirement often seemed to prove a limiting factor, because the
services were required to use an appointments system which was less than optimal
for their needs.

Filing
systems

Four
services stored all their files within their own space. Others were divided
between divisional and main hospital filing departments. In these cases, files
for hearing aid clients, and often also summary cards for other high priority
clients such as infants were kept in the clinic.

Where the
clinic had its own filing system, simple manila folders were the norm.

Stock management systems

Only one of
the services used a computerised stock control system. This consisted of an
Access database. One of the city audiologists consulted commented that the Noah
hearing aid performance system which she used was about to introduce a stock
control package, and this could well be a valuable innovation, given the
usefulness thus far of the Noah system in storing client data.

SATELLITE CLINICS

Pros,
cons

In a few
cases, audiologists expressed satisfaction with the way their satellite clinics
worked. Mostly, however, they were a cause of concern to them. Concerns included
time spent travelling to and providing the clinics, transportation of equipment,
and the fact that some groups of clients (eg child hearing aid clients) were
hardly more likely to attend these clinics than the hospital-based clinics.

Similar services

Only one of
the hospitals surveyed does not have any rural clinics in its area of influence.
In another case, there is a rural clinic, but provision is subcontracted to a
private provider.

Rural
clinics range from 1-3 hours from the base hospital. In the case of the 3-hour
clinic, staff make a habit of flying to attend clinics.

Patient criteria

In all but
one case, the primary aim of the clinic is to provide ORL support. In one case,
this support is provided by an audiometrist. In two cases, follow-up for
paediatric hearing aid clients is also provided. In one area only, follow-up of
adult hearing aid clients is the only service provided.

STAFFING

Position in hospital organisational structure

In one
case, where the organisation is obviously fairly flat, the audiology service is
located in the hospital service. In three cases it is located within Surgical or
Surgical/Medical groupings. In all other cases it is within Clinical Support,
Disability Support Services, Allied Health, or a combination of these groups.

Management

In all but
two cases, the senior audiologist was responsible to a General Manager of the
hospital service. The two exceptions were responsible to Unit Managers of their
particular sub-service. In one area currently responsible to a General Manager,
a proposal is under consideration to transfer responsibility to the Outpatients
Manager. In the one city hospital service (not part of the main survey) where
this is the case, this has not proved efficient – with up to three levels of
management attending most meetings because of poorly delegated authorities.

Staffing levels

The average
number of budgeted FTEs for qualified audiologists over the services was 2.0,
with a range of 0.8 – 3.2. However, the average of currently filled positions
was only 1.1, with a range of 0.1 – 2.2. These data indicate a severe national
shortage of audiologists employed in the public sector.

In
addition, all but one service employed audiometric technician/s. The average was
0.8 FTE, with a maximum of 2.0.

Data
comparing the FTEs budgeted and actually filled (and also including
non-qualified audiometric staff – the Total Audiology figures) as a function of
population served are given in the following Table. These highlight the effects
on services available of the shortage of audiology staff.

Measure

Mean

Minimum

Maximum

Population/Audiology position budgeted

69,316

27,164

119,003

Population/Audiology position filled

201,335

54,327

854,304

Population/Total Audiology position budgeted

49,448

21,731

74,503

Population/Total Audiology position filled

70,840

36,218

140,933

In
addition, an average 0.8 FTE support staff (range 0.3 – 1.2 FTE) were employed.

Roles & responsibilities of
Audiology staff

Titles and
job descriptions for the head audiology positions varied from area to area. In
almost all cases, however, management of the audiology department was included,
and in many cases, a specified amount of the person’s FTE was set aside for
carrying out administrative duties. Two areas did not have a designated head
audiologist – these were both areas with a single audiologist employed
part-time. In both of these places, dissatisfaction with the status quo was
expressed.

Technicians
when employed, were supervised by the head audiologist in all but the two
above-mentioned situations. Duties varied according to the needs of the service,
and the capabilities of the individual, but essentially were restricted to
routine tasks, or involvement in more complex tasks with the active role being
taken by the audiologist.

NATIONAL TRENDS

Current
issues and impact on current and future services

There was
little awareness among audiologists interviewed of changes in the national
context.

A range of
issues were brought up when this topic was introduced – two audiologists
expected further privatisation or subcontracting of services to occur in their
areas. Another referred to increased funding their service had received related
to child health and Maori health priorities. One area was perceived to have
sub-standard services which needed drastic improvements.

LINKS

Links
to ORL services

Relationships between audiology and ORL services varied from provision of
regular ORL support by audiology to very independently run services with a large
number of reciprocal referrals. In a few cases, the services were physically
close. In all cases, audiologists expressed satisfaction with the relationship.
In a few instances audiologists wished that they had even closer communication
with ORL specialists, and in one case, the audiologist was aware that there was
a similar wish from ORL practitioners.

Links
to disability services

In four
cases, audiology was organisationally linked to DSS. In another case, they
shared space. In one case, there was no contact, and in a second, very little.

Links
to key community providers

By far the
most important community resource as far as audiologists are concerned are
hearing therapists. Relationships based on 2-way referrals are the norm. One
audiologist who also practises privately commented that her relationship was
stronger through her private practice, because of a policy of purchasing therapy
sessions for hearing aid clients. In one area, the therapist sometimes attends
appointments with clients. In one area, the hearing therapist was the first port
of call for clients with malfunctioning hearing aids. Some audiologists
expressed interest in improving even further the relationship between themselves
and hearing therapists.

Relationships between audiologists and the Deaf Association were very limited,
primarily because they have few clients in common.

Vision
hearing technicians generally had good relationships with audiologists. In one
case, a VHT was employed on a part-time basis by the audiology service to assist
with paediatric assessments.

Advisers
on Deaf Children are generally seen as close colleagues by audiologists. In one
case, the relationship is seen as needing improvement, and the audiologist is
motivated to work on this. Links with itinerant teachers of the deaf are
sometimes strong and sometimes nonexistent.

Other links
seen as important to varying degrees by audiologists are Speech Language
Therapists, Public Health Nurses, and Community Health Workers. General
Practitioners were occasionally mentioned. In several cases, audiologists
commented that they received direct referrals from GPs.